. as a couple of people have already said, the 1st version of the physician payments sunshine payment sunshine act was introduced in 2,007 by senator grassley and senator cole. i think if you called your bookie in september of 2,007 order washington lobbyist and say what are the odds that this thing will become law, they would have said it would have been pretty unlikely. we had investigations by senator grassley and the senate committee. we had high profile media coverage of the issue of conflict of interest and payment to physicians state laws that require this kind of reporting at the state level and created a compliance nightmare for companies that made them more willing to entertain a federal law but we also had within the medical profession that was important, the institute of medicine the american

association of the association of american medical colleges issued a report calling for much stronger conflict of interest standards, leaders standards, leaders with individual schools saying we just cannot keep going. all of all of those things came together, and the law passed in 2010. but the other piece of context that i think is not proximal to the law's passage but is important to understanding how it fits is this sort of much wider recognition that we really need to understand in this country that drivers of health care costs and where the dollars go, and if you go back to 2,007 it would be close to unimaginable that cms would be publishing individual physician payment records. and so we now have the 1st report from the sunshine act

3.7 million dollars in payments. that's around nine billion a year, funds that that are either going to research and product development which is important and important for the public to understand are going to drive uptake of particular products which is also important and important understand. where are where are we now? pew has been involved for a long time. and since passage we have continued to work with the a working group of consumer organizations and individual countries to build shared understanding of how that data should be represented. data for the 1st full year

of reporting has now been collected. it will be submitted to cms in march and in june we we will have publication of the 1st full year of data along with some delayed publication of data that for various reasons was not released from the 1st five months of data. so the law is moving forward the question is what happens now. let let me give you three thoughts. one thing that i think will happen one that i think probably we will happen and one that is important but we will take some concerted effort on the part of stakeholders if it is going to happen. what will happen is the process of submitting data we will continue and be refined and we we will have this year the 1st full

year of data. what probably we will happen is the center for medicare and medicaid services will continue to refine the way it presents the data. the 1st website was not very user-friendly. it was pretty difficult to go on there and find your own physician, but cms put up a much more user-friendly tool. and the agency tells me that they continue to work on refining the user interface improving the search tool, but also thinking about how to provide the data in context by medical specialty, geographic location with time trend things that they are thinking about.

the 3rd thing is something i am not sure will happen it creates a lot of descriptors for payment marketing, and those are not defined and some of them are overlapping. what we suspect and do not no is that companies are using the terms in different ways. if the data we will be useful and comparable across companies going forward they we will have to be a concerted effort from stakeholders outside to sit down and say, well, what do what do we mean when we use this descriptor category. there is also an ongoing discussion about how to provide context of the state of. the law allows for

individual essentially a comment field associated with each payment. what companies have not use that. what i hear is that they probably will not. from a a compliance.of view they don't want someone on the front lines to be free texting into an individual payment field. so we are left with how the public interprets the payments. we have some context. these other kinds of payments. the needs to be an ongoing payments of developing. there will be a need for ongoing societal process of

which we are concerned about, which we are okay with and what they mean. and so that culture change in medicine that i talked about that helps to drive the move toward more transparency we will have to continue. and so the data in the public domain is really an incredibly important step in the result of a lot of hard work by the people here and people across the country in the industry, industry, and there are a lot of committed people who are spending time and money. by the way, learning some interesting things. we realized we were paying the same guy from five different budget lines.

>> so, i am bill jordan president-elect of the national physicians alliance. i am going to talk about the influence of pharmaceutical companies and doctors and also as the leader of an organization that is taken on this issue as one of our core issues around professionalism. i have no disclosure in terms of receiving payments. we are founded in 2,005 on behalf of patients and build a community that really advocated for professionalism and restores integrity and trust in medicine.

we do we do not receive funding from pharmaceutical companies or device manufacturers. let's let's talk about some of the problems of the entanglements that we have that the industry. so taking a page from 12 twelve-step, we admittedly are powerless. my name is bill. they often think that everyone around them is influenced by pharmaceutical manufacturers but that we ourselves are immune to influences. this was highlighted in the digital medicine report talking about undue pursuit of financial gain. the gray area is what is and undue pursuit. however, it is clear that these entanglements have an influence on clinical care research and education and

it even roads public trust and healthcare. it is also clear that pharmaceutical companies target physicians. drug reps -- there is an error. 38,000 in 1995. so this is old data. with the cost of of about 12 to $13,000 per dr. in the country, which is enormous you can see on the chart on the right that detailing to doctors made up about a quarter of promotional spending. and actually more than half of the promotional budget was connected to free samples. samples. i will never and talk about that because i have asked to

talk about the gaps that the movement forward and transparency are not addressing. mainly this budget going to free samples. some 94 percent of doctors have a relationship with pharma. doctors self-report that 83 percent took food or gifts. almost the same number took free samples. they lack insight regarding this as a general rule and generalists of which i count myself one perceived to sales calls per day. unfortunate our clinic has been sales reps. about four intended not. samples everclear affect on doctors. this this was a sample case that was offered to doctors.

you try lifestyle changes and move on to prescribing medication. 27% said they would dispense a free sample and the court or so they would give the free sample even though it was a different medication them what they thought would be best for the patient. more more troubling is that this patient went on to get insurance 17% of the doctors would continue the free sample medication after the patient was short. there is good data as well that banning samples increases prescribing of first-line drugs like the most appropriate drug for that patient. i would say overall free samples are misdirected and unsafe. unsafe. often thought that they go to the poor. often they often they go to the friends of pharma reps are doctors. and there is really a lack of quality safeguards and

are more often subject to black box warnings that come out. obviously it is a major marketing tool that is expensive to healthcare. increasing patient out-of-pocket expenses accounts for a large portion of pharmaceutical promotional expenditure and is a main a main driver in the increase in spending. out of a huge portion the ones that are most promoted are driving most of the spending. this is a report from ims health talking about affordable cost avoidable cost of the health care system, data from 2012. $213 billion. major chunks are nonadherence often due to patients not being able to afford the medication prescribed antibiotic over

prescription which is often linked to promotional activities and underutilization of generics obviously there are a lot of samples alternatives some of them are challenging such as universal health insurance and government negotiation with prices. generic options and all the other things that are listed here including barring them from academic institutions and using unbiased pharmaceutical education. i will flash up on the screen a few examples. called the unbranded dr. about getting pharmaceutical influence out of the dr.'s office. we went on from their to find the top five list of things that doctors should avoid.

they good stewardship project. this is one example of questions that came out of that in terms of asking your dr. what do you need this medication or procedure. it it is needed to engage in this issue. obviously a lot of speakers have spoken about the open payment system at length which is been getting better as time goes on and these are just a review of statistics already offered. the number of individual physician records has gone down but hundreds of thousands of physicians in over $3 billion and that's just over five months. 1300 teaching hospitals that

speaks to the.of the formulary of particular hospitals being influenced by pharmaceutical companies. companies. obviously they clarify these issues to the public. this is one example of the dr. that was making 124,000 in speaking fees for physicians are already paid much higher in the us than in other countries. you will see that we have been a great partner in this. the schools and academic affiliates which don't always have the same roles. there is free information on drugs including this example from consumer reports conflict free. it has been funded by an attorney general grant and we have worked with partners to get information out to

academic institutions around the country and practicing physicians to change the culture and become more aware of the seriousness of this issue. we can use transparency for good. i am hopeful that this will continue. it it acts as a shaming tool for better or worse. also it allows for the possibility for the loss of peer respect and affects patient opinion. they are concerned when they find out the dr. has received payment from a manufacturer and can have implications around conflict of interest. obviously we need to follow the money to no where most of it is going and how to improve the situation.

this is a quote taken from a panel around the iom report. report. i hope that this will be a springboard for action. >> i just want to highlight a couple of key points. one is that their were a lot of different industry players both pharmaceutical and medical device manufacturers that embrace the idea of transparency. some did it because of consent agreements initially but moved forward being very open to the issues around transparency and some are voluntary leaders.

there was not massive industry opposition at least at the federal level. as alan said, said, it has changed the business practices. but, there really really was a coming together saying that this information can be valuable to the public. i also want to.out rodney's. on clinical research and the value of knowing when researchers have conflict of interest. senator grassley's office did an amazing series of investigations that highlighted some of these conflicts that were not being reported, reported, and several medical journals have change their practices on disclosure and you can

here that from the doctors as they got up today. that is a lot more common, and we think it is beyond the legislation itself, a good thing for people to no. a couple other points limits on coverage. the physician payments sunshine act was targeted toward physicians. different states have expanded coverage to other prescribers, nonprofits or others that engage in conversations around the use of medicine or around healthcare decision-making and i think that that is an area for further exploration as we look for where this legislation will evolve and information that is still missing. finally, missing. finally, i think that the amount of work being done to actually pull out insights from this data i do also want to commend pro-public and pro- public and others

who have been tirelessly trying to look at correlations and then finish with a question and open it to the floor. rodney because i think his bosses set the standard for transparency in a variety of ways. in particular the legislation or push to cms release the payments directly to doctors my question for you how do you think that that we will transform what we know about the industry relationship with doctors and about prescribing patterns and other health care utilization issues? >> we don't but we we will more. that is sort of the value of that almost simultaneously having cms release medicare

payment data to providers and the physician payment sunshine act, the open payment website coming online within months of each other. it does it does provide opportunities to look at the payments and the practice. it will give us information to see what is going on that we will inform us in the policymaking realm as to what might be necessary, what necessary, what might be things of interest or not and again, consistent with the theme from sen. grassley, senator grassley we are better off with more information unless. >> my next question if question, if i am sitting at home as a consumer and want

to no these relationships how do i go about getting that information? what is the best resource that you think is out there for consumers to understand this new disclosure database >> i think right now there is some context information on the open payment. very general descriptions of what is meant by the different payment types. beyond that i think that you need to look to a a variety of resources, and different people we will make different decisions about how they interpret and value payments, payments, but you can look to organizations consumer reports, consumer union as well as to industry websites and continued medical education companies and so on.

right now people need to read broadly so that they can make up their minds. corrections often easy to tell whether somebody sees drug reps or not, and they should be looking at their doctors to see what money they are taking from pharmaceutical companies that we will be useful. it is less useful to figure out what the affect is on individual drugs. the patient is not going to no what is in the pipeline but they should have a conversation with their dr. 's. i think patients should not see dr. suzy drug reps. i misspoke about the 40 percent.

about one out of four doesn't sue drug reps at all birdies to plenty of doctors out there. >> and a similar question. you talked a lot about samples. i have been offered samples. one of the questions i ask is a consumer that is offered to make much they know. we know that can to work. i think that all patients should ask the dr. i have alternatives to what your offering. the pros and cons including the costs. and that that often leads to a better decision for the patient and the dr.. it is great for patients to become more aware and think twice about seeing doctors that have a clear a clear farmer representative coming into there office.

it is not always possible but i think having more of an activated patient makes a huge difference in terms of thinking about these issues like i have to say that samples of the most effective marketing tool and it would be worth it to see the look of on the dr.'s face when you hand back a sample and say, i'm sorry, can i have an older time tested medication please. >> please. >> you also mentioned consumer reports as another place i would like to open up to the audience. raise your hand and we we will get your questions for this amazing panel.

i was interested in what you said about how pharma companies have different marketing companies other getting out there getting into the dr.'s son plays baseball wasn't all that. is that a relatively new thing and can you give examples of what they're doing. it is not actually new. physicians know a drug representative is better to sell them something, they are not being suspicious of the receptionist or golf partner. if partner. if a marketing message gets conveyed through that person it is much more effective. marketing

messages are not necessarily about using a specific drug. it might be that excessive sleepiness is not a joke. it is a real condition. loki is a tragic epidemic. why a particular competing particular competing drug is so problematic that no one should prescribe it. every. every drug, 15 to 20 marketing messages associated with the. it's difficult to figure out. >> other questions for the audience? >> thank you. i you. i am here on behalf of the cme coalition. you raise an interesting.during your discussion about marketing practice. one thing you mentioned is one thing that might go

unchanged is the practice you see around continuing medical education. and there are many firewalls in place to ensure that accredited cme providers are prevented from allowing pharmaceutical companies or other commercial supporters to have any undue influence over the content of those cme events the speakers are any influence on the attendees. as you also may know this is an issue that has come under consternation during the rulemaking process. and essentially change their position or interpretation as many as five times whether payments should be reported. my question for rodney and the panel, you may be able to provide context but especially considering the unique reporting challenges considering that that firewall is in place to make sure the medical device

manufacturers are pharmaceutical companies do not have any influence and do not know for example through the speakers are being recruited for those events, how can we overcome reporting challenges? with her conversations on the political side about whether those payments should be reported and are their any other thoughts on the panel about reporting for continuing medical education? ..

but we right now are in a position that i think cms is moving at an appropriate speed where cme is concerned. we know that they have bounced around a bit and it's challenging because the issue of regulation that says one thing and they pull it back slightly and assess another so "the wall street journal" piece is one word seems somewhat confusing to us but i think it's because of the fact it's been confusing but ultimately this is one that's ongoing but it's getting where

we are right first before fully jumping in. that is where we are standing. >> i would just add to that i think cme has always been a tricky issue and for folks who are deep in the weeds here to maintain a practice to get a certain amount of continuing medical education every year. and what has happened over the past decade and a half is more and more of that continuing medical education has been funded by the drug companies are the companies that make certain products. and the challenges as the questioner pointed out does funding always pass through intermediary and technically been understood that grant and there are various laws in place. everybody who looked at this from a senate investigations to medicine to the american medical colleges report have all expressed deep concern about the

potential of cme funding to influence prescribing but it's been a technical issue tricky issue of how you capture so what cms seems to have come down on and has bounced around as saying if the company finds out within a year that their funds were used, went to a particular affordable payment that's consistent with how other indirect payments other payments through an intermediary are treated in law. so that is where it stands now. >> adriane did you have something you wanted to say? >> is the most effective covert marketing that doesn't have. pharma does not find what doesn't help pharma. and the firewalls are basically

a joke. pharma may not be telling a communication company who they should have speak or what should they speak on but the company knows who to invite and who not to invite and the concept of an unrestricted educational grant is only unrestricted if nobody the events says something that pharma doesn't like. i have experience of speaking at a pharmaceutical company funded cme where the drug reps packed up their booth and left after my talk in the pharmacy company withdrew its funding. >> i think it's a deeply troubling issue. most doctors there is the money to have conflict free contains medical education so there really isn't a need to take from drug companies. so this is very challenging and i think there's a real issue

with the transparency around the specific issue because it's not clear that disclosure helps us much in this issue. the audience often says it's great that they are being honest or they are really an expert because they get money from five different pharmaceutical companies. or it just ends up being a brand recognition and the guerrilla advertising. so it's really challenging to make this work and i don't think there are good solutions other than really us as a profession paying for cme and not relying on industry financing. >> by the way we have a list of farmer free continuing medical education on our web site. >> i feel like we have talked a lot about pharma as a part of the sunshine act and it also covers medical devices where there are strong industry require sometimes by the fda to use it particular medical

device. allan can you talk a little bit about medical devices because i don't think we have touched on them much today. >> i want again to echo something you said earlier say that we work closely with a number of companies including device companies that are so fully committed to being transparent about these financial relationships and i don't want to shortchange that commitment in any way. on the question with the device off in the drug you prescribe it's a fairly simple process on that level but with a device there is often hands-on training to use it so there is a much more intrinsic relationship there and medical centers who develop conflict of interest policies have often treated those device reps somewhat

differently from porter circle -- pharmaceutical reps. >> other questions? >> i am jesse kirsch from d.c. and he talked a lot about the powerful marketing ability of these examples the reps give to doctors. is there any other use for those samples to the reps? are they conducting testing testing using these samples as trials in any way and secondly the ethics of the involvement with drug reps which has been talked a lot about this morning is that something that is starting to be incorporated into medical school ethics classes in the secondary extra education that doctors get? >> samples are purely a marketing device and they do not serve, they do not serve a purpose.

they are the most effective marketing device. schools, some schools have incorporated training about interactions with drug reps. i have to say a lot of the training is really bad especially when it's done with industry drug reps and industry will sometimes cooperate in these programs and medical medical students are then left with the question that there are good drug reps and bad drug reps and you should avoid the bad drug reps and only deal with a good drug reps which is not really good message. the messages you should not see drug reps and that needs to be modeled as well as top. they will adopt with their mentors are doing. >> i wanted to echo that in terms of limited utility of free samples. i think their issues that the drug reps are not supposed to calm use them for any sort of

study. that's for fda approved uses is what they are supposed to be restricted to but there are some schools doing education around this. where i teach we do have a class on this and bioethics series and i actually lead a session for all of the students during their ambulatory rotation around the patient that comes than and has been put on a bunch of samples and the complications of that and how you entangle from now. >> other questions from the audience? >> hi on barber with the college of emergency physicians so this is of great interest to us and as has been discussed we have been all over the map trying to work with their media people as to what the rules of the game are.

in listening to the conversation and i'm beginning to think would it be good to have somebody else here to represent another point of view because it seems like everyone is on the same page. one of my question was and i'm not sure if it was in this section and the aca or the original will rank. parsing something down to $10 to me seems absurd and that is what happens with a lot of the things, many things in the aca where by the time you got down to the rags in the guidance it's become almost absurd. i was wondering if he could talk a little bit about that. >> the a 10-dollar limit was in the law itself. >> the demand in the standard which was created legislatively and ultimately became part of the regulation and we have seen through the early rollout that certain manufacturers when they reported data they went below

the $10. cms when we spoke to them they had a challenge and what to do with that and they went with the decision that ultimately if it was reported should be published. i think working with manufacturers down the road as to whether or not they would whether or not they will accept publish below $10 will occur down the road. something else you said. i think again and i hope we have, i have been clear about this representing us in my office in the work we have done here, this is a conversation and anything that you hear here respective positions that is taken that drug reps are evil that conversation. that is for you and your doctor. if are an educated consumer and

this is where we would encourage you as a consumer learn more. you make complex economic decisions as to what are the things you want and do not want all the time. think about the amount of work you put into determining your cell phone and the service you want. that windows thing i don't know how that works and t-mobile you have your sprint and at&t and where my getting this from? you go through and make complex decisions and value judgments is an educated consumer. we have the responsibility to do the same as the patient so would a walk and you will never have the amount of information that your m.d. does because they want to medical school but you can engage in an informed conversation. so if you see information about what your provider has taken as part of this database you can

ask questions. you can engage in that is what we encourage. if you want to take absolutist positions as your role as a patient that is your right and you now have that tool but you also have just as much of a right to engage in conversation and that is where we will continue to push. if the day occurs where we have information out there that allows us to take positions of an absolutist nature and make changes because we look at the consequences and the research shows us that that is also out there for us as a matter of policymaking. >> i think it should be 1 dollar because what research shows us is small gifts have a larger impact than large gifts. i won't go into the experiments but when you receive this ball gifted it changes your opinion more because nobody likes to think that they have been bought off by something small where is it you are given something small small -- large you are suspicious. if you're given something small you change your opinion and you

think it's because it's an independent change and you don't think you are affected by the small gift. i would be happy to share that research with you. >> other comments? >> you are right that there is a burden associated with tracking and reporting and the sheer number of payments and that's a byproduct of the drive for transparency. it may well be overtime and i'm not sure which 10-dollar gifts members are concerned about but it may be overtime companies just say we are going to do fewer sandwiches and the doctor say we don't actually need the sandwich so i think time will tell. >> i am will schaffer and while the disclosure i am the medical director for the academy of surgery and no other disclosures. part of this conversation is

confusing to me. obviously there is industry supported cme that is all about selling their product and selling their devices and that's very clear and there are cme programs such as what we have put on that are blinded in either the papers that are picked are blinding to this surgeons who are picking those papers to be delivered. i guess i'm directing this more to rodney because we have discussed this in the past. i don't believe the intent of the law was to discourage association cme and continuing medical education. you said this is legal behavior but yet it's very clear that we are parsing this into legal but immoral or legal but disdainful behavior and i don't think that's the intent of the law.

i will try as hard as i can and keep at it which is immoral and disdainful eye reject associating that with my remarks and my boss's remarks. in the case of continuing medical education it is an ongoing conversation. it's something we is warranting further conversation that we are not leading the charge let's go there right now particularly because of the complexity. we talk about journal articles and that's one where the ability of a manufacture provides journal articles to providers out there and whether or not that should be reported. it's one that you and i spent time time on and that's a challenging one absolutely but ultimately i am comfortable with

sitting down with my provider and asking about a payment showing up in the database and having her tell me that this is related to learning more about this condition which you don't have but another patient may have and that is why that was there. there are choices. it's to not take it, to take it in reported or to purchase it on your own. those are legitimate choices and providers have the opportunity to make those and then the reports go to the database and the patients can ask. we continue to believe that's totally legitimate and legal and attaching -- we are not rushing to attach judgment here and i hope i can continue to make that case successfully here. >> can you wait for the mic please?

>> the idea that a physician should never talk to a pharmaceutical rep or a device rep is like saying please go find a cell phone but you cannot talk to a vodafone. you can't talk to verizon. you can't talk to at&t and i still believe that this country those behaviors are not legal. >> i get the point and i realize i'm sitting next to judgment here and i will give her the opportunity to make her case but we are not there. we don't necessarily agree with something. i cannot wait to go to my wife on our upcoming anniversary and tell her that i heard that gifts were more meaningful so i'm just saying. [laughter] i am just saying that this snickers bar versus dinner in a nice restaurant, i am just saying i heard this was the

case. >> you said she is watching. >> i'm just saying so again i want to make sure there's a distinction between the remarks i'm making and where we stand with legislation and some other things you are hearing from my colleague. >> and to rodney's wife who is watching she can ask for a large gifts. >> probably people in the audience don't know that when i undergo surgery there is often a device rep in the operating room assisting the surgeon although they are not allowed to touch the patient. if you are afraid about relationships between drug reps and positions you should be way more afraid of the relationship between medical device rep sent positions. this contributes to using untested devices and people may or may not know that medical devices don't have to have been

inserted in a human being or tested in human beings before being put on the market. we have had many disasters with orthopedic surgery and many other medical devices where we have learned about the dangers after they have been in use. this is a complicated discussion that we don't have time to get into but there's a lot of ethical and a lot of not just ethical discussions but real patient harm that results from the relationships between medical device reps and surgeons. >> in the back. >> good morning. thank you very much to the panel and thank you to the national panel on coalition for putting this discussion together. it's interesting from my perspective sitting here i'm representing where diseases -- my name is marion o'dea and i represent individuals who have

a -- trips and deficiency. alpha-1 is a genetic lung disease that individuals develop even if they have not smoked and for people with rare disorders i will tell you that we used to quote that it took seven years to diagnose this but in october of 2013 the national organization for rare disorders did an on line survey and they are now saying it takes at least 10 years or more. 20% said it takes 10 years or more. one of the ways physicians learn about this disease and learn about the treatment is by cme and dolls so dealing with drug representatives in hearing about meeting patients who have this disease to often go in with the drug reps to talk about their disorder and how they were diagnosed. so i wonder if he could make some comments. many of the things that have been said make a lot of since

when we talk about common disorders but not necessarily rare diseases. and i have a few other questions. i wanted to ask you if you you could design invented diseases and whether or not you think that's by guidelines being revised because of pharmaceutical companies or whether that refers to drug licensure parameters and then how should patients be educated to understand transparency and what should the transparency be for voluntary health agencies that serve patient interest? >> a lot of questions there. adriane i'm going to let you start particularly because she did mention issues of invented disease and the question was what about the people that have a rare disease that many people haven't heard of. is this transmission of information helpful to the agency? >> consumers are important in this conversation and consumer

advocacy organizations for rare diseases and other diseases are important that a compromise is what they have to say when they are taking money from forests -- pharmaceutical companies. there are organizations like the national women's health network and the national breast cancer action rather and health research group. there are consumer advocacy organizations that do not take money from ford -- pharmaceutical companies but arcs jamell active at getting health issues and topics that don't receive enough coverage covered. even if you are a small organization you can still get attention and get the word out without pharmaceutical money in terms of invented diseases this has also been called disease mongering by lynne payer or selling sickness. and i use it to refer to

conditions or his industry calls them disease states that have literally been created by industry and put forth through third parties because they will hire and convince leaders and advocacy organizations etc. to make particular conditions accepted so social anxiety disorder and some of the others we talked about before. these are actually invented out of whole cloth. i don't remember what the other questions were. >> we have met on numerous occasions and i get your point and particularly for coming back to where we have been again and again which is a provider who wants to become more educated says okay and no provider should be uncomfortable talking about it. i don't remember if this was you who gave this is a case or you

brought someone from iowa who talked about this. and i was sometimes we'll have physicians rotating between different hospitals so they will walk into different surgeries and we discussed in one hospital they have a certain type of device for a hip replacement or knee replacement. so being able to come in and consult the manual instructions related to that is important to have on-site and if it has gone missing or is not their being able to get one immediately. if that is counted as part of that. if i come to you and say there was this report on open payments that talked about this but at this amount and you can tell me oh yeah that was to get the instructions on hand for the purposes of your knee replacement i am good with that. that's a good thing. i want to keep posing that there are potential positives here.

we are not an absolutist position here. the opportunity to gain education is something that's available and no one should be afraid of it. really no one should be explained -- afraid of explaining to their patient. if you're comfortable with that then that's your concern. if you aren't comfortable as a provider having a conversation that should be concerned but so much about we talk about and marion where you went i would be incredibly happy to have my provider be able to tell that it's related to me. this is where i got it and there is this rare disease and i have this because i was talking to someone. i consider that valuable. >> allan d. want to comment? >> just a couple of thoughts. one is that it's taking 10 years to diagnose your rare condition than the system isn't working. that's the first thing to say and i think beckwith made him an syndrome or something that

doesn't have a drug treatment. so we have got to have a system where diagnosticians are learning about rare conditions and are not dependent on the makers of products to teach them how to diagnose and nobody here is saying alpha-1 trypsin is not a real condition. say very real in serious condition and has to be appropriately diagnosed and treated. >> i think it's very challenging to get everybody on board with information. it's a huge operation to obtain medical education and in general. you could say that's a failure of the profession to reach out to advocacy organizations to learn about these health issues like alpha-1 antitrypsin

deficiency and to really educate providers about this. i would not necessarily say that becomes a justification for getting funding from medication manufacturers or device manufacturers. i think that we want to know about these things but we also want to empower patients to ask simple questions that can be very powerful. the same way i said either other treatment options? what are the pros and cons of those? every patient should be empowered to ask their provider either other diagnoses that we should be thinking about? i been suffering with these symptoms for a long time. i don't feel like i have a good handle on what's going on. are there other things we should be considering? i think having an activated

patient is often the key to solving these issues and can be applicable across a lot of rare diseases not necessarily one specific one. >> i would like to use the last couple of minutes for a lightning round. obviously this is the law of the land. we have heard a lot of areas in which it can be expanded from the panel and needs to be approved from the utterance. what are one or two things you would like to see either with the physician sunshine after other ways of improving disclosure that you think will be next steps going forward? rodney we'll start with you. >> it is cms' ongoing work improvement of the web site. we look at it in the next two or three years for that to become accepted, respected expected and that it works. that to us is what is most

important right now. outside of that we can talk about other issues but that is where i think we are right now working to be reestablished. >> let's have required disclosure for all organizations national regional and local weather medical advocacy or anything related with health. >> i mentioned a few this morning that are within the scope of the current law and beyond the scope of the current law. would be lovely to have other health care providers governing. >> i definitely agree with making a web site function as well as possible so we can easily see outliers in the profession so that can be used to drive culture change. >> join me in thanking this panel and the national coalition on health care and john for hosting this event. [applause]

[inaudible conversations] now we go live to the virginia state capitol in richmond where governor terry mcauliffe delivers the state of the commonwealth. this is live coverage now on c-span2.

>> we are still waiting for the virginia state capitol where governor terry mcauliffe will deliver this to the commonwealth address. he has been the governor for one year now and this is live coverage on c-span2. it should start shortly. [inaudible conversations] >> sergeant at arms. >> mr. president his excellency the governor of the commonwealth of virginia. [applause] [applause]

[applause] [applause] [applause] [applause] [applause] >> thank you very much. [applause]

[applause] [applause] [applause] [applause] >> as speaker of -- the joint

assembly and his excellency the governor of the commonwealth of virginia the honorable terence mcauliffe. [applause] >> thank you. thank you. thank you everybody. lieutenant governor northam, speaker howell chairman stosch men and women of the general assembly, distinguished guests people of virginia thank you for inviting me here tonight. and i want to especially thank the first lady of virginia my wife dorothy mcauliffe who is actually here with us tonight. [applause]

i especially want to thank dorothy for her compassion her energy, her commitment to making sure that -- not one single child sits in a classroom too hungry to learn. thank you. [applause] and finally i want to thank my cabinet and the thousands of virginia employees that they represent for the hard work and dedication. folks just one year ago i stood at this very desk and shared my vision for a stronger, more

independent virginia economy. in that speech i expressed optimism that we in this chamber could find common ground and advance the causes that virginians care most about, job creation, economic development education and health care. one year later i am proud to say that optimism was well-founded. i want to first thank chairman jones, stosch and cold and for working with me in a bipartisan fashion to balance our budget responsibly. thank you gentlemen. [applause] we also worked with a bipartisan coalition to reform the standards of learning. we took the first step in reforming workforce development

and we began tackling the challenges that we face in our mental health system. and mr. speaker i want to thank you for working with me and my team to make our transportation planning process more about economic good than political maneuvering. thank you mr. speaker. [applause] we built in our commonwealth helping more businesses expand and bringing companies here to create jobs and grow and create wealth for everyone in the commonwealth of virginia. those efforts i'm led to their paying off. in the years that we have been working together i am proud to announce that virginia has closed 267 economic deals resulting in $5.58 million and

capital investments which is more than twice any administration has done in their first year in office in virginia history. [applause] [applause] as you know new jobs and building a stronger and more diverse virginia economy has been the primary focus of my time in office. i'm proud of the success that we have had winning individual projects like the 2000 jobs that we are bringing to chesterfield county with tranlin paper company or the unitao pharmaceutical project which will create 376 new jobs by keeping a plant in petersburg

open that was closing and adding 100 more jobs than were slated to be lost at that plant had closed and i want to thank the representatives from tranlin who traveled here in unitao pharmaceuticals for joining us this evening and for your kind continued partnership with our great commonwealth. now if we can stand and give them applause. [applause] [applause] i am appreciative but i have got one more. now let's bring your corporate headquarters to virginia as well. [applause] i was proud to help close the first economic development deal and the appomattox in more than 12 years and the largest deal

that they have done and over 44 years. we brought a chinese company back that took over a shuttered plant. we have reopened that plant with billions of dollars in new investment and guess what? we are now manufacturing in that plant pollution control devices that will be manufactured now in virginia, shipped to our port and those manufactured products are now going to be sold back to china folks, that is a new virginia economy. [applause] last year i stood in this chamber and announced my goal to make virginia the east coast capital for agriculture and forest tree exports. that wasn't empty rhetoric. we got right to work.

i have posted over 20 ambassadors to the governor's mansion to discuss trade opportunities for virginia. we have traveled the globe selling virginia agricultural products everything from apples to whine to soybeans to peanuts. i have even eaten my fair share of fried potatoes and chicken pause. folks, i will e anything if it brings investment to the commonwealth of virginia. [applause] and i'm so pleased to announce that our efforts are paying off. for the first time in the history of the commonwealth of virginia agriculture and forest tree exports for the first time ever last year exceeded over $3 billion in exports. [applause]

we outcompeted 200 cities across the nation to bring stone brewing to virginia and we beat out mexico for continental automotive's major expansion in newport news. and i was just there the other day with a 100 million-dollar investment from canon for newport news. as you all may know by now i love my job. attracting new business investment to virginia is an essential part of being governor and we are having unprecedented success. but if we are going to continue our momentum we must invest in smart incentive funds like the governor's opportunity fund and a agriculture and forest tree industries development fund. these tools make virginia competitive in a global economy

and they provide a real return on investment both in terms of economic activity and revenue to our budget. for every dollar we invest in the virginia economic development partnership, we receive $9 back in budget revenue in return. folks, this is simply too good of a deal for taxpayers and the session i look forward to working with you in a bipartisan way to preserve and expand these important investments for virginia. [applause] given that virtually all of the current governor's opportunity fund balance is obligated to future projects it is my hope that we can work together to preserve these investments and continues to reap the benefits they bring to virginia's families.

i am also proposing legislation to strengthen management and oversight of the virginia tobacco indemnification fund so that we can maximize return on investment and preserve this important driver of economic development in the tobacco region for many many years to come. [applause] as we worked to attract new business today we also have a responsibility and an opportunity to lay a real foundation for economic growth well into the future. when i talk about building a new virginia economy that is exactly what i mean. that is the economic infrastructure will take to outcompete 49 other states in 200 nations around the globe even in the face of damaging defense cuts and economic headwinds. when i presented my budget

proposal last month i spoke of the impactor sluggish economy has had on our state revenues. virtually all of that drag has been created by federal policy decisions, the most damaging of which we know is sequestration. automatic federal budget cuts reduce military contract in virginia by $9.8 billion between 2011, 2012 and 13 and according to a george mason university study they threaten to eliminate 154,000 jobs in the commonwealth which is about 4% of our workforce. and if congress does not act by october 1, we could be looking at around another $50 billion in additional cuts nationwide. that would have a

disproportionate effect on our economy particularly in northern virginia and hampton roads. even in the face of these cuts are close relationship with the department of defense and the federal government will contain and i intend to continue fighting for every single dollar we can get. i was proud to work with senators warner and cain and their congressional delegation to help fight off the effort to decommission the uss george washington aircraft carrier. if that happened happens we would have lost thousands of jobs in the commonwealth. i was similarly thrilled to help convince the united states state department and the general services administration to choose our own fort pickett is the new home of the foreign affairs security training center which will bring as many as 500 new jobs and millions and millions of dollars in investment with it.

federal spending will continue to be an asset to our economy. but there's no question that the foolish sequestration policies born out of the dysfunctional congress is doing real damage to our economy and to many virginians quality of life. what remains to be seen as however spohn to this new reality that the days when virginia could simply rely on federal spending to buoy our economy in both good times and bad are over. if we are going to preserve virginia's position as a global economic leader we must open up new avenues for growth that are not dependent on federal government spending. we must grow, we must strengthen and we must diversify. to sum it up we must build a new virginia economy create folks, this is our time. [applause]

if you look at the policy actions that my administration has taken the proposals that i've said before the general assembly this year, you will find that every one of them comes back to creating new economic opportunity for all virginians. i know many of you will agree that the first step we must take to achieve that goal is to develop a world-class workforce in the beta program so that our employers get the employees they need in a 21st century economy. we know that virginia is the home to the best workers on the planet. we owe them a workforce development system that prepares them for economic success, from infancy all the way through adulthood. [applause]

most of you in this room have heard me say this many times. we have employers across virginia today that have thousands of high-tech jobs available but they cannot find trained workers to fill them. if we are going to keep these companies in virginia, and bring in new ones we must build a world-class workforce system that better aligns our training programs with the needs of our employers. this session, i am proposing introducing a bipartisan workforce development package that increases state funding for workforce programs, devotes greater state attention to apprenticeships and training in much-needed areas and increases accountability and transparency for the millions of taxpayer dollars spent on a broken system

that we have today. by streamlining our efforts in reducing redundancies we can get students the skills that they need to succeed while being better stewards of taxpayer dollars. there is no question that building a healthy virginia economy requires giving every virginia veteran the opportunity to live a meaningful and productive life here in virginia. [applause] [applause] [applause] i am proud of the work that my administration is doing encouraging companies to hire veterans particularly through the virginia values veterans

program. in just over two years that the three programs 234 member companies have hired nearly 7000 veterans. and let me say this, one of them is here with us tonight. as travis johnson and it is distinguished 12 year career in service as a marine sniper, he found himself struggling to translate the unique skills that he developed in the military into a successful civilian career. fortunately systems technology forum av three certified company met travis and recognized his enormous contributions that he could make to their company despite his lack of formal professional training. travis is now working hard and getting further training so that he can advance in his career and

after hiring 41 veterans in their first year with the program s.b. -- stf has committed to me today that they are going to hire 20 more veterans this year. [applause] [applause] so travis, thank you. [applause] [applause] travis thank you for your service to our commonwealth. thank you for your service to our nation. i would add that my son

graduated from the naval academy this year so he has just joined the marines and i hope you can give him some advice. [applause] folks this session i'm proposing to further enhance the v3 program by offering a performance grant which will recognize employers who meet goals for hiring compensating and retaining veterans. additionally we should ease the transition from military to civilian life by passing legislation requiring the virginia community college system 20 word greater credit for the skills and training veterans receive during their time in military service. [applause] these men and women have served and sacrificed for us so let's work together to get them the

skills, training and economic opportunity that they deserve. as we improve our workforce development system we cannot forget that our economic future runs through public school classrooms across this great commonwealth. that is why my budget contains no program cuts to k-12 education. [applause] [applause] and no additional cuts to higher education. [applause]

public education is the backbone of a healthy economy so let us pledge tonight to avoid acrimony on this topic and agreed that we will not cut a single dollar from schools during this legislative session. [applause] if we are going to lead in a global economy, we cannot wait until our students reach kindergarten to begin preparing them for success. last year as you know i formed the first-ever children's cabinet as well as the commonwealth council on childhood success and i asked them to take a 360-degree approach to increasing economic opportunity for virginia students from before birth all

the way through adulthood. and we are already making great progress. i was proud to work with united states secretary of education arne duncan to help secure a $17.5 million grant just last month to expand their preschool program so that another 1600 ad risk four ad risk for year-olds and can now learn in a pre-k classroom in their community. [applause] [applause] we will put every federal dollar that we can get to work preparing our students but it's equally important that we make pragmatic use of the money that we are to have so i have introduced budget language that

will allow communities who have exceeded their pre-k budgets to receive leftover funds not used in other divisions so that they can offer more children and a great start to their education that they deserve. [applause] i'm also proposing legislation to keep our children safe by increasing the number of daycare facilities across virginia that are licensed and properly inspected by the state and local governments. [applause] just as some students need a little extra encouragement sometimes entire schools need additional support. i have included funding in my budget to help train principals in areas with underperforming schools so that they can steer their teachers and students toward greater academic success.

and a key element of increasing student achievement we need to make sure that every child in the commonwealth of virginia has access to quality nutrition. [applause] early last year dorothy and i met with united states secretary of agriculture tom vilsack who informed the two of us that virginia was leaving millions and millions of our federal dollars on the table that could be going to feeding hungry children in school. the first lady has put this issue front and center and we are already seeing spectacular results. i'm proud to say that already 89 virginia public schools have already enrolled in a brand-new school nutrition initiative which enables qualifying schools to serve every student breakfast

and lunch at no cost to the student. [applause] ..

>> >> and pass the virginia dray matt and i will sign it into law. [cheers and applause] my budget proposal may skied

investments in research and technology infrastructure. i have loved for pre-to millions of we can compete for the new eye on an electronic billing dash electrical lab at newport news. that new 1600 -- six and $80 million facility would create 4900 jobs of the decade and had 708 million to the commonwealth economy and also will make virginia a world leader in high energy physics and and let me be clear. our soul competition is the state of new york recently cannot let those new yorkers come down to virginia to take our project from us. [cheers and applause]

i space could get you going. [laughter] it took a little time. [laughter] pretty good. [laughter] a and in full disclosure i came up with that myself. [laughter] to improve the cybersecurity infrastructure as you know is a top priority. this is one of the few areas the federal government will make major investments in the coming years and we have an opportunity here in virginia to the. soon after taking office i launched the virginia cybersecurity commission chaired by richard clarke

who has a bias to three presidents on national security and counterterrorism issues. they're continued work and diligence coupled with the vast array of ethics that we are having the commonwealth puts us in a strong position to win the new proposed cybercampus i am also working very hard to make virginia a leader in bioscience. we just convened the first summit of all the universities and invited to come together i invited the world-renowned expert from m.i.t. with over 100 patents to better leverage on private assets to compete if we work together starting today we can succeed where others have failed before. with the and tangled web of the workforce development system so works for students

in business is the and the economy with the skills and training they need for the job of today and we can make sure every step of a child's development puts her on a pathway to economic success and a new virginia e. economy also to have the opportunity for those who have made mistakes and paid their debt to society. [applause] virginia residents like james, a vietnam veteran who returned from the gulf of tonkin a different man. he came back a changed man perot when he went. but he did his time and

reformed his life. he deserved a second chance to be a productive member of our society. and i was honored personally the other day to restore his rights to be part of what he called the greatest day of his life. i've made restoration of of a civil or voting rights of former offenders a central focus of my is administration and i am proud to say that in one year we have restore the rights of over 5200 former offenders and that is more than any governor has ever done in their history of the commonwealth of virginia. [applause] as we work to build a new

virginia economy every person can get the skills the intriguing and opportunity they need we must be sure that no virginian those without access to quality affordable health care. [applause] people who can see a doctor when they are sick without incurring devastating cost can realize the full economic potential the people without coverage are one illness or accident away from economic ruin. if we build the new virginia e. economy we must get those hard-working men and women in the care that they deserve a and the truth is we have already paid for its with one vote this session we can get health care for 400,000 of our fellow

virginians and save our current budget $105 million. with one vote. we can ensure hospitals across the commonwealth can stay open to eliminate a key barrier to economic success for so many thousands of our friends and neighbors. with one vote we can show the world that virginia is a place where public good comes ahead of partisan politics so let us come together at the table to take that important vote this legislative session. [applause]

as we continue this important discussion i will continue to implement our health care plan, a health the virginia, just today just in the last few hours hours, we learned that more than 290,000 virginians have already signed up for the new health insurance of the federal marketplace of just the first month of open enrollment. [applause] many of the people who signed up so far are newcomers to the marketplace but many others are just reviewing the plans that they purchased last year. i've met one of them last month starting her own

business, a hair salon for a half years ago and she told me it was a real struggle for her to afford health care. she had a plan but it was limited and expensive last year she got help sighting of for a better plan through the federal marketplace that is more affordable and offers prescription drug coverage that the previous plan did not offer. she is just one reminder that a healthy economy needs help the citizens and i am glad that she was able to enjoy it does here tonight in congratulations and good luck with your business. [applause] last month rejected another step forward to implement a

health the virginia with a 2.$6 million federal grant to pursue health care delivery innovations that will result in better care and lower cost for virginians and just this past week the gutter's access plan begin processing applications to insure that 20,000 virginians with serious mental illness can get the medical and behavioral care they need to feed the lives that they deserve. a health the virginia is no substitute for medicaid expansion. but it is creating real opportunities for thousands of virginians who desperately needed. i cannot think of a better investment than that.

[applause] as a street in the teeming capital with a group work force training we must also enhance the infrastructure upon which our three economies is built with transportation and energy generation and transmission ports, airports these are the building blocks of our system in the new virginia e. economy they are the envy of the world. thanks to the leadership of many of you who are here today we have made great progress in the is and construction but there is more be must do to build the infrastructure that we need to drive our economy into the future increasing access to real is a key element to ease congestion to expand

economic opportunity. yesterday chairman chris jones and i announced a compromise legislation plan to provide local governments with more access to a transportation front and pump the dollars into rail and transit projects so we can expand our transit infrastructure without raising taxes. [applause] thank you another challenger must tackle to gather is reforming the public-private partnership program as a vital tool for our transportation network but as we learn to after we we staff $300 million and still counting on route 460

of road that not a single shovel has been put on the ground nor had one permit even than requested to build the road. so our program is open to mismanagement and abuse. and i stopped all funding on route 460 and i will stop every project that waste our virginia taxpayer dollars. [applause] so this year we have a set of common sense bipartisan reform that will improve the program's transparency, and minimize taxpayer risk and to ensure greater accountability. the ports of virginia is one of our greatest economic assets the gateway to the world of international

commerce. this year we have seen record breaking growth of shipping containers going through that facility and thanks to the leadership of the board in the executive director of real making great progress. but one year ago i stood here and was disappointed because the port was losing millions of dollars per car i had to discover that for years it was not even meeting their debt covenants but those days are over. we're looking at everything we can possibly do to make sure we are protecting the core economic assets for us to grow of this commonwealth. the energy sector holds tremendous potential. and development the the potential will be unfulfilled if we are complacent. this session you advocate for legislation to increase the diversity of fuel mixtures utilization of zero

carbon that sources such as solar wind and nuclear. the growing techniques and technologies will not all the help of virginia create new jobs will also reduce our emissions as robert to mitigate the impact of global warming. we will increase regulable development by creating the virginia solar development authority and introduce legislation to create an energy development fund to provide a virginia with another tool to attract job-creating businesses can to help them grow. work force development education and health care and infrastructure are the essential ingredients to a strong economy to know that it is home to transparency and accountable government i

want to applaud both chambers of the assembly for returning to richmond with a serious purpose to reform our ethics laws demands and refers to an office i honored a campaign pledge to put a $100 cap of guests on myself, my family and administration and their family and i'm confident that by the time of the jury will have made $100 cap on all kiev's which is a standard for all virginia public officials. [applause] with that cap we should do establish a bipartisan ethics commission with real investigative powers to offer guidance on the lot to identify and sanction those that they violate i hope you will pass my proposal to for

have been a fund-raising activity with regular and special sessions. right now the only thing that makes special sessions special is we can still raise money but now we can work to erase that inconsistency and additionally it is our opportunity to adopt a common sense position that people who sit on boards and commissions should be prohibited from voting on matters that benefit their family members, themselves or their business partners. [applause] if we pass these common-sense measures we can restore virginia stress to reestablish our reputation for well-run government that puts results first. we should also reassure families that we serve we're

doing everything we possibly can to keep him safe weekend a longer stand by as our fellow virginians are lost to prevent preventable access of gun violence as a gun owner myself i fully believe that law-abiding citizens have a right to loading carry firearms but as we have learned too many times with too many tragedies there is a difference between responsible gun owners and those who violate the law or likely to use firearms in a manner that endangers lives. i have proposed several restrictions for virginians to keep them safe if we work together this session in these proposals will keep

him out a dangerous hands by closing again show people. [applause] by preventing violent criminals and domestic users from rotating fire arms. [applause] and revoking concealed carry permits from those who do not meet their legal obligations to pay child support and again trafficking by a restoring the one gun a month lot that we had here in virginia. [applause]

even one virginians precious life is too high a price to pay for our inability to reach a reasonable compromise on gun safety. before i move on i want to recognize someone special his name is colin and is here with us tonight he is a survivor of the 2007 shooting averages detect were 32 students were killed along with faculty members. he was shot four times that young indians still has three bullets in his body and i want to thank him for coming here tonight to stand by our side every step of the way to make virginia a safe place for our families. [applause]

as we were to recover committees from gun violence reavis to write by the people gore on the front lines every single day to keep the family safe. you have heard me talk about this before in a find appalling that sheriff's deputies to risk their lives to protect virginians often earn so little they qualify for the supplemental nutrition program i pledge to raise deputy pay and i am proud to say here as governor to honor that commitment to raise the pace of the average starting paid a salary for the end -- the deputies is no longer so

though that these brave young men and women qualify for food stamps i went to thank our share of story we hear tonight to help with this legislation and to represent every man and woman who puts on a law-enforcement uniform to keep virginia saved. thank you. [applause] in addition to virginia every person has an equal right to succeed regardless of his or her race, gender, religion or

sexual orientation and i am proud to say it is a great year for many virginians the supreme court decision to legalize same-sex marriage in virginia and other states leaves the decisions about marriage are now left to loving adults instead of their government. [applause] i was honored to take executive action to bring the government in line with the decision including allowing same-sex couples to provide adoptive homes for a child who needs it. this session we have an opportunity to update the remainder of the code of virginia to reflect this historic decision in doing so we can send a message to

the more than 90% of the fortune 500 companies that protect their employees from discrimination that frigidity is a place where prosperity comes before the outdated culture battles. our is his the commonwealth that was founded on the values of equal rights we make virginia stronger when we work together to expand these rights and not restrict them and i promise to be a brick wall against any legislation that would the road women's access to quality health care.

[applause] and i am proud to stand here when your leader not one single woman's health clinic has closed in the commonwealth since it took the oath of office to five. [applause] i have asked the board of health to revisit the uterus regulation is a letter threatening to shut down clinics that provide essential services like cancer screenings in regular checkups and i told them take the politics out of the regulatory process to focus on safety and science in the reality of a woman's constitutional right to make her own health care decisions with their own

doctor. [applause] [cheers and applause] in a new virginia e. economy everyone will precede equal pay for equal work regardless of their gender today a woman in virginia makes just $0.79 for every dollar a man makes. this is unacceptable and it is hurting our community and our economy. so this session i will introduce legislation to increase the penalties that those that fail to pay equally for the hard work that they do and as we read of the pay disparities we will send a of message that virginia is a leader to keep

them safe from the threat of domestic violence earlier this year i greeted the it task force to combat sexual violence on college campuses chaired by the attorney general to develop the broad based approach they're already doing great work and will deliver recommendations to me by june but there are several steps we can take together now to make our communities safer and i am proposing that the state council of higher education develop a unified sexual conduct policy for all of virginia public colleges and universities by july 31st of this year and also proposing that public colleges and university places a rotation on academic transcripts and cases where a student is

dismissed from that institution for violation of the school's sexual misconduct policy student code of conduct was university honor code i know these are difficult and challenging issues but i know if we work together we can make our schools get our communities safer. i would be remiss if i didn't mention our hard-working state employees to wake up every single day determined to make virginia a better state in which to live they deserve eric thanks for their hard work and dedication and often challenging circumstances but in addition to our gratitude let's be clear. our state employees deserve a raise. [applause]

i included a 2 percent pay raise in my proposal that i paid for with the savings of the coverage gap i was disappointed to see that remove from the final budget well the revenue picture prevented me from the budget i submitted died on monday with like to see our final compromise include a raise for our state employees. let me be clear i am open to that idea if you come to me with a plan to raise pay i will give it the consideration that it is due as long as it does not cut education or health care and other essentials services. [applause] as w